Harvard Political Review: As Chairman of the DNC, you were credited with helping to elect a Democratic majority in the House. How would you do that in 2014?
Howard Dean: And the Senate, just to be modest.
You would have to renew the 50 state strategy, first of all. Second, the campaign should really be starting right now, identifying Republicans who are way outside the mainstream.
The reason we hold the Senate today is that over the last two election cycles the Republicans have nominated people who are just wholly unfit for office in key races. We should make a case that a number of people in the Republican majority are wholly unfit for office, and we should really talk about their record.
The 50 state strategy was designed for the long term, not the short term. Because it was very successful—and because we have a Democratic President, who tend to view the DNC as part of their reelection apparatus—the strategy has gone by the wayside. It’s a mistake to abandon long-term electoral strategy.
HPR: What do you see as the role of Organizing for Action in all of that?
HD: It’s well intended, but President Obama didn’t get elected because of the issues. He got elected because he represents a new generation. They tried this four years ago, and it didn’t particularly work then and it’s not going to work now. You can’t mobilize all these young people who were mobilized because Barack Obama is Barack Obama—not because he stood for this or that or the other thing.
HPR: When Obamacare was being drafted, you were a pretty vocal advocate for including a public option. Are you optimistic that the idea might come back to the public debate?
HD: There won’t be much more of a public debate on healthcare, unless the implementation is a disaster—in which case there will be a public debate about whether to get rid of the whole thing. That’s what I’m worried about. Basically, that vote determined that we are going to have universal healthcare in this country based in the private sector.
HPR: Do you see a route to eliminating fee for service medicine, which you’ve said is the solution to healthcare cost problems?
HD: I do. It’s in the [ACA] actually. Although, the people who wrote the bill had no idea that it could happen.
Accountable care organizations were put in as a way of vertically integrating the healthcare system to improve quality of care. But, the fact is that if you have a vertically integrated system of healthcare delivery, that ACO can go into business as a health management organization essentially. If they do that, they can compete with the insurance companies and beat the hell out of them because the costs are dramatically reduced, as they would be in a single payer.
An interesting thing about Obama’s bill is that because it tracks Romney’s bill so closely, you can see what’s going to happen in Massachusetts. In Massachusetts, the insurance companies are buying up hospitals. That’s really the beginning of the end of fee-for-service medicine in the long run.
HPR: What do you think of as the timeframe for the end of fee-for-service medicine?
HD: It’s hard to say. Relatively slowly. The first thing that’s going to happen, and much more quickly than anyone in Washington wants to admit, is that small businesses are going to get out of the health insurance business altogether. That’s going to happen very quickly. Then, the next thing that’s going to happen is that medium sized businesses are going to follow. In 10 years, the only people that are going to be offering healthcare as an employment enticement are the really high-end companies with the high-end workers or very large companies, which either have union contracts they can’t change or prefer managing their own healthcare costs.
If we’re going to see the end of the small group market—because most of it is going to end up on the exchange with individuals—then that’s going to happen. The administration never anticipated that happening. That’s going to blow a hole in the budget because most of those people are going to be entitled to subsidies.
HPR: Shifting gears to gun control. When you were governor, you had a strong record with the NRA. But you have had some harsh words recently, saying their office “was filled with crazy people.” What has changed?
HD: Their national position on guns is nutty. The NRA is an organization that has members who are mostly reasonable people who hunt and don’t use an AK-47 to hunt deer—mostly because they don’t like their deer burger made in the field. What they’re doing in Washington is simply saying crazy things to attract the fringe. When you take a position that 90 percent of the public is opposed to, that’s about power and money and certainly not about guns. I don’t recognize this NRA from 20 years ago when they endorsed me eight times.
HPR: Who is your 2016 pick?
This interview has been edited and condensed.